You tell me, you're the PA!

While many PAs come from medical backgrounds, few of them are called on to make the kind of decisions that we often do, such as determining if someone lives or dies.

Part of being a PA is learning to live with the immense responsibility that comes with having the authority to make high-stakes decisions with our patients. One of my PA school instructors always talked about role-transition and the challenges new PAs face when moving from a previous job to becoming a PA. While many PAs come from medical backgrounds, few of us were called on to make the kind of decisions that we make as PAs, sometimes literally determining if someone lives or dies. It can be something as small as missing a medication interaction, or something as big as being involved in a level-one trauma center code event.

I was an athletic trainer before becoming a PA, and in that setting we were constantly reminded that we weren't licensed to practice medicine, that we were not ever to make a diagnosis, etc. I once attracted the wrath of a physician when I was telling him about an athlete I had seen, and that based on his sudden leg swelling, I thought it possibly indicated a circulatory problem. He put up his hand right in my face, said “STOP!” and proceeded to remind me that I was NOT there to diagnose.

Becoming a PA was indeed a role transition. In my clinical year almost 18 years ago, I struggled mightily with my case presentation, always stumbling with the part where I offered an opinion about a diagnosis and made a recommendation about treatment. I had one preceptor who responded to a particularly weak case presentation with “Jim, there is absolutely nothing that you just told me that I couldn't have gotten from my MA,” then wheeled around and walked away. Ouch.

But, she was right. And it got me moving away from drafting an aimless, plan-less presentation toward realizing that I HAD to end a case presentation by saying, “I think the patient has this, and I think we should do that.”

Fast-forward 18 years, and I'm much more comfortable about making decisions. Because that's what PAs and other medical providers do. I do notice that many of my nursing colleagues who used to work in outpatient settings struggle with the recommendation part of a presentation. There is a great tool which comes from nursing called SBAR (situation, background, assessment, recommendation) which really helps frame nursing presentations, and I'm always encouraging nurses with whom I work to end it with, “I think we should do this.” It's a hard thing for some nurses and medical providers to do. And it takes practice.

I recently saw a patient about a medication, and we had differing opinions about where to go with the dose. I wanted her to increase the medication, and she was not so sure. But after discussing it in a very positive discussion, she said, “You know what, you think I should increase the dose. And while I'm ambivalent, I am here in this facility because I need your help. Otherwise, why should I bother coming here if I'm not going to take advantage of your skills, your training, and your professionalism? You're the PA, not me. So, if you think I should make that change, then let's do it!”

A few weeks later I passed the patient in the hallway when they had another appointment with a different provider, and as she walked by she smiled and said quietly, almost whispering, “You were right!”

It was an inspiring moment; I kind of felt like we should charge down a ramp onto a field in preparation for the big game. It really made me remember the almost sacred responsibility that comes with being a PA: the responsibility to know what to do for our patients, and know when and how to do it.

ClinicalAdvisor.com is for nurse practitioners and physician assistants, offering the latest information on diagnosing, treating, managing, and preventing medical conditions typically seen in the office-based primary-care setting.

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